Minnesota Health care News May 2013

May 2013 • Volume 11 Number 5

Pediatric bipolar

disorderJoel Oberstar, MD

COPDAmit Chandra, MD

Foodborne illnessApril Bogard, MPH

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Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601;email [email protected]. We welcome the submission of manuscripts and letters for possible publication.All views and opinions expressed by authors of published articles are solely those of the authors and donot necessarily represent or express the views of Minnesota Physician Publishing, Inc., or thispublication. The contents herein are believed accurate but are not intended to replace med-ical, legal, tax, business, or other professional advice and counsel. No part of this publica-tion may be reprinted or reproduced without written permission of the publisher. Annualsubscriptions (12 copies) are $36.00. Individual copies are $4.00.

MAY 2013 MINNESOTA HEALTH CARE NEWS 3

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PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Janet Cass [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR MaryAnn Macedo [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

www.mppub.com

MAY 2013 • Volume 11 Number 5

WOMEN’S HEALTHBreast cancer screeningBy Annelisa Carlson, MD, MS,and Ellen L. Abeln, MD

CALENDARDon’t Fry Day

BEHAVIORAL HEALTHPediatric bipolar disorderBy Joel V. Oberstar, MD

POLICYCancer in the workplaceBy Lindy Yokanovich, Esq.

PUBLIC HEALTHFoodborne illnessBy April K. Bogard, MPH, RS

TAKE CARECaregiver stressBy Chris Rosenthal, MSW, LISW

INSURANCEViatical settlementsBy Paul Hanson

7 PEOPLE

NEWS4C O N T E N T S

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PERSPECTIVE

10 QUESTIONS

PULMONOLOGYChronic obstructive pulmonary disease (COPD) By Amit Chandra, MD

DRUG CLASSCorticosteroidsBy Anita Sharma, PharmD, andChrystian Pereira, PharmD, BCPS

Maureen Gaedy

Goodwill/EasterSeals Minnesota

ElizabethMaloney, MD

Partnership for Healing andHealth, Ltd.

Exp. Date

� Check enclosed � Bill me � Credit card (Visa, Mastercard, American Express, or Discover)

Please mail, call in or fax your registration by 10/17/2013

MINNESOTA HEALTH CARE ROUNDTABLE MINNESOTA HEALTH CARE ROUNDTABLE

Background andfocus: For the major-ity, end-of-life is themost medically man-aged part of life. With it come complex issuesthat involve economics,ethics, politics, medicalscience, resources andmore. Advances in technology are extend-ing life expectanciesand require a redefini-tion of the term “end-of-life.” It now entails alonger time frame thanone’s final weeks orhours and debate as to when life is reallyover. Mechanisms existto facilitate personal

direction around this topic, but there is a need for improvedcoordination among the entities that provide end-of-lifesupport.

Objectives: We will discuss the significant infrastructurethat supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontol-ogy, and hospice. We will review the elements that go into creating advanced directives, societal issues thatmake having them necessary, and the difficulties encoun-tered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improvedin the future.

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota

Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

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Thursday, October 24, 2013

1:00 – 4:00 PM • Symphony Ballroom

Downtown Mpls. Hilton and Towers

Advanced careplanning

Addressing end-of-life issues

F O R T I E T H S E S S I O N

Many with DiabetesAre Unaware of It,MDH SaysApproximately 80,000 adults inMinnesota may have diabetes and not know it, say officials with Minnesota Department ofHealth (MDH).

MDH officials note that thepercentage of adults in Minnesotawith diabetes nearly doubledbetween 1994 and 2010 and thatthese numbers underrepresentthe true number of people livingwith the condition. About 290,000adults in Minnesota, or 7.3 per-cent, have been diagnosed withdiabetes, but officials say nationaldata suggest that another 80,000Minnesotans may have the dis-ease and not be aware of it.

“Diabetes is a very treatabledisease and it is important thateveryone with diabetes takessteps to get their blood sugarunder control and lead a healthierlife,” says Minnesota HealthCommissioner Ed Ehlinger, MD.

Officials say anyone can takea simple paper or online test atwww.diabetes.org/diabetes-basics/prevention/diabetes-risk-test to check his or her risk for diabetes or prediabetes. Thosewith a high score are encouragedto follow up with a health careprovider.

Legislators ProposeCutting HHS Budget In March, House and SenateDFLers proposed cutting thestate’s health and human services(HHS) budget. “It’s going to swal-low up our entire budget,” saidHouse Speaker Paul Thissen (DFL-Minneapolis), who recommendedcutting $150 million from thebudget. If enacted, the cut wouldreduce the governor’s proposed$11.3 billion budget for health andhuman services to $11.2 billion.“It’s the part of the budget that’sgrowing too quickly to keep upwith the revenues that are comingin,” explained Thissen.

In response, a letter signed by

more than 50 groups, includingthe Minnesota HospitalAssociation, the MinnesotaMedical Association, Children’sDefense Fund–Minnesota, theMinnesota Safety Net Coalition,and Hennepin County MedicalCenter, called for Senate andHouse majority leaders to recon-sider the HHS cuts.

The health and human ser -vices budget serves some of thesickest, poorest, and oldestMinnesotans and the agencies,hospitals, and nursing homes thatcare for them. The House andSenate have proposed budgetincreases for almost every otherstate agency.

U of M ExpandsParkinson’s Research The University of Minnesota hasbeen named one of five clinicalsites for BioFIND, a two-year, mul-tisite study that has the goal ofdiscovering new Parkinson’s dis-ease (PD) biomarkers. Biomarkersare biological indicators of a per-

son’s health status and are usedto help researchers and cliniciansbetter diagnose, understand, andtrack the progression of a givendisease.

One example of a biomarkeris blood sugar level, which canhelp determine if a person hasdiabetes and, if so, whether thatdisease is progressing. Research -ers also use biomarkers as toolsin developing disease-modifyingtherapies to slow or stop the pro-gression of disease.

Paul Tuite, MD, an associateprofessor in the university’sDepartment of Neurology, leadsthe BioFIND study at theUniversity of Minnesota MedicalCenter. “This research is critical to our efforts to help find a bio-marker for Parkinson’s disease, adisease that affects the centralnervous system in an estimatedone million people,” he says.“With the support of the MichaelJ. Fox Foundation for Parkinson’sResearch (MJFF) in partnershipwith the National Institute ofNeurological Disorders and Stroke(NINDS), we hope to learn more

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about PD and ultimately put us onthe right course for a cure.” Tuiteand the University of Minnesotahave an established history ofresearching PD and therapy for it.

“Since our foundation’s incep-tion, we have invested $65 millionin the pursuit of Parkinson’s bio-markers,” says Mark Frasier, PhD,vice president of research pro-grams at MJFF. “Finding such biomarkers would allow scientiststo predict, diagnose, and monitorthe disease, and determine whichmedications might work andwhich won’t. Biomarkers would beinvaluable tools to the develop-ment of new treatments forpatients. We’re optimistic thatBioFIND can play a critical role inthis search, and look forward toworking together with the Univer-sity of Minnesota and NINDS.”

Tuite and his research teamseek volunteers to participate inthe clinical research study.Candidates are men and womenover the age of 55 who have hadPD for more than five years, aswell as men and women over theage of 55 who do not have eitherPD or a first-degree blood relativewith PD. (A first-degree blood rela-tive is a biologically related par-ent, child, or sibling).

BioFIND studies are alsobeing conducted at ColumbiaUniversity Medical Center, NewYork; Rush University MedicalCenter, Chicago; Cornell Univer-sity Medical Center, New York; and the University of ChicagoMedical Center, Chicago.

BioFIND is sponsored by the Michael J. Fox Foundation for Parkinson’s Research and fun -ded in part by the NationalInstitute of Neurological Disordersand Stroke.

North Memorial,MultiCare OpenUrgency CenterNorth Memorial, along withMultiCare Associates, has openeda stand-alone emergency room atBlaine Medical Center. Officialssay the North Memorial UrgencyCenter will be similar to a regularhospital emergency room, and

will be staffed by physicians fromNorth Memorial’s Level I TraumaCenter.

A stand-alone emergencyroom at a medical office buildingis new to Blaine, but the idea hasbeen cropping up in the TwinCities metro area recently. TheAbbott Northwestern–WestHealthEmergency Department inPlymouth, for example, opened inJanuary.

The North Memorial facilitywill be able to care for the samekinds of illnesses and injuries thathospital emergency rooms see,officials say, including chest pain,sports injuries, broken bones, car-diac arrest, abdominal pain, andconcussions. Patients that needhospitalization can be transferredto North Memorial Medical Centerin Robbinsdale, officials say.Patients also will be able to getfollow-up treatment at the adja-cent MultiCare Associates clinic.

HealthPartners JoinsHeart Attack InitiativeBloomington-based Health-Partners has joined a nationalpublic-private health initiative thataims to prevent 1 million heartattacks and strokes by 2017. TheMillion Hearts campaign waslaunched by the U.S. Departmentof Health and Human Services in2011 and includes numerous stateand federal government partnersalong with private groups such asKaiser Permanente, Walgreens,and the American MedicalAssociation.

As a partner, HealthPartnerswill set goals for cardiovascularmeasurements and strategiessuch as aspirin use, blood pres-sure control, treatment of highcholesterol, smoking cessationefforts, reducing sodium intake,and cutting fat consumption.

“HealthPartners has a longtradition of investing in programsthat prevent disease by keepingour patients and membershealthy,” says Michael McGrail,MD, MPH, vice president andassociate medical director forHealthPartners Health Solutions.

News to page 6


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You’ve worked hard all your life. You’ve raised a family, taken care of others and served your community. Along the way you’ve had some fun, experienced some heartache and prepared so that one day you could enjoy the retirement lifestyle of your dreams. Well, that day is here and we provide a lifestyle where you can do everything you want, while we take care of everything you need. We make the repairs; you can come and go as you please. We do the cooking; you do the dining. We do the driving; you enjoy the ride. We do the landscaping; you smell the roses.

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Officials say the efforts haveresulted in clinical outcomes thatinclude 90 percent of membersbeing tobacco-free and more than85 percent of HealthPartnersMedical Group patients with car-diovascular disease and diabeteshaving their blood pressure undercontrol.

ACA BenefitsMinnesotans’Preventive CareMore than 70 million Americans,including 1.4 million Minneso-tans, have received free preven-tive health care services becauseof the Affordable Care Act (ACA),federal health officials say.

Health and Human Services(HHS) Secretary Kathleen Sebeliusannounced in March that approxi-mately 71 million Americans inprivate health insurance plansreceived coverage for at least onefree preventive health care serv-ice, such as a mammogram or flushot, in 2011 and 2012 because of

the ACA. HHS also estimates that34 million Americans in Medicareand Medicare Advantage planshave received at least one preven-tive service. Officials say that, intotal, 105 million Americans havebeen helped by the ACA’s preven-tion coverage improvements.

According to Ellen Benavides,Minnesota assistant commis -sioner of health, Minnesota issimilar to other states in the num-ber of people receiving preventiveservices under the ACA. She saysthat removing copays from pre-ventive health services increasesaccess to such services. “The ben-efit of that is that you have peoplewho access services that we allknow improve the health of popu-lation,” she says.

However, Benavides adds, the data from the HHS reportshow that there are continued dis-parities in how different ethnicgroups access preventive ser -vices. “We’ve got enormoushealth disparities despite makingenormous investments in ourhealth care system,” she notes.

Two Mayo HospitalsTo CombineMayo Clinic is combining its twoRochester hospitals into one facil -ity, officials announced in March.Effective Jan. 1, 2014, Saint Mary’sand Methodist Hospitals willbecome a single licensed hospital,named Mayo Clinic Hospital.

Mayo Clinic currently has a “single integrated hospitalpractice” divided between twohospital licenses and two legalentities, a relationship createdduring a reorganization in 1986.The two hospitals file separatereports on quality, financial, andoperating data to organizationssuch as the Centers for Medicare& Medicaid Services, the JointCommission, and the LeapfrogGroup. Officials say such report-ing has increasingly resulted inan incomplete and incorrect pic-ture of Mayo Clinic’s care.

“We know patients seek infor-mation from government andnongovernment entities to obtainimportant quality and financialdata,” says John Noseworthy, MD,

president and CEO of Mayo Clinic.“By continuing the integration webegan in 1986, patients can have amore complete, accurate pictureof the care we provide at MayoClinic.”

Health InsuranceExchange Becomes LawOne of the most controversialpieces of health care legislation inthe state’s history, a measure tocreate a health insuranceexchange for Minnesota, has been signed into law. Theexchange goes into effect Jan. 1,2014, and will be called MNsure.State agencies say MNsure willsave Minnesota families and busi-nesses $1 billion in health carecosts by 2016. With ACA tax cred-its, officials say, individual con-sumers could see an average 34 percent decrease in premiumsfor insurance purchased throughthe exchange.

News from page 5


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Patrick J. Flynn, MD, received the David King

Community Clinical Scientist Award at the

39th national meeting of the Association of

Community Cancer Centers in Washington, D.C.,

in March. Flynn is a medical oncologist and

medical director for the Cancer Research Program

at Minnesota Oncology, where he has practiced

since 1985. The award recognizes active commu-

nity clinical research leaders. Award winners are

physicians who have demonstrated leadership in the development,

participation, and evaluation of clinical studies and/or who are active

in developing new screening, risk assessment, treatment, or support-

ive care programs for cancer patients. Flynn has been vigorously

engaged in clinical research for many years.

Hennepin County Medical Center (HCMC) has added staff at its

Alternative Medicine Clinic in Minneapolis. Acupuncturist Jessica

Brown, MOM (Master of Oriental Medicine), is

licensed by the Minnesota Board of Medical

Practice and is certified by the National Commis-

sion for the Certification of Acupuncture and

Oriental Medicine. She earned her degree from

Northwestern Health Sciences University in

Bloomington, Minn., and completed an advanced

studies program at Tianjin University of Tradi-

tional Chinese Medicine in Tianjin, China, with

training that emphasized severe conditions such as stroke and other

neurological disorders. Prior to joining HCMC, Brown was an acupunc-

turist at the Acupuncture Health Center in the Southdale Medical

Center, Edina. Her areas of special interest include pain management,

oncology support, women’s health issues, and post-stroke rehabilita-

tion. Chiropractor Ben Backus, DC, specializes

in treating patients with chronic and acute muscu-

loskeletal pain and dysfunction. His areas of

special interest include treating patients with

back, neck, and extremity pain, and headaches.

Backus earned his doctor of chiropractic from

Northwestern Health Sciences University and is a

member of the American Chiropractic Association

and the Minnesota Chiropractic Association.

The Minnesota Medical Association (MMA) and the MMA

Foundation has presented Therese Zink, MD, MPH, with its Physician

Leadership in Quality Award. The annual award

recognizes a Minnesota physician whose efforts

advance quality health care. Zink received the

award for her leadership of a practice-based

research study on the effective management of

chronic kidney disease in primary care settings.

Zink practices family medicine and is a professor

in the Department of Family Medicine and

Community Health at the University of Minnesota

Medical School.

John Manion, MD, has received the 2013 Trustee of the Year Award

from Aging Services of Minnesota. Since 1994, Manion has served

on the board of directors at Saint Therese, a nonprofit that provides

senior care services and housing in the Twin Cities metro area. He

established a palliative care unit at Saint Therese, the first of its kind

in the Upper Midwest.

P E O P L E


Patrick J. Flynn, MD

Ben Backus, DC

Therese Zink, MD, MPH

Jessica Brown, MOM

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Maureen GaedyGoodwill/Easter Seals

Minnesota

Maureen Gaedy isa mission services

director withGoodwill/Easter

Seals Minnesota,overseeing its

medical equipmentloan program.

Goodwill/EasterSeals helps peopleovercome barriers

to education,employment, andindependence inorder to achieve

their goals.Believing in thetransformative

power of work tochange lives, this

nonprofit organiza-tion helped more

than 15,000 individuals receive

70,000 services in 2012.

Goodwill/EasterSeals provides

job skills training,work experience,job placement,mental health

counseling, andno-cost loans

of medical equipment.

magine that you or a family member neededto stay at home to heal from an accident, sur-gery, or debilitating illness. Now imagine that

you needed a wheelchair or other durable medicalequipment during your recuperation. Could youafford to purchase it? What if your insurance com-pany’s authorization and reimbursement for thatequipment took weeks to approve? Or worse, cov-ered only a small portion of your costs?

That scenario is all too real for many Minnesotans.That’s why Goodwill/Easter Seals Minnesota loansmedical equipment to the public—at no cost—inthe Twin Cities, Rochester, Willmar, and St. Cloud.More than 11,000 people borrowed 19,434 piecesof medical equipment in 2012.

How it began

This loan program began in St. Paul in 1987, afterGoodwill merged with EasterSeals, an organization thatfocused on helping individu-als with disabilities and otherbarriers to independence.Additional loan program siteswere added in 1995.

Every piece of medical equipment in our inven toryis donated. We constantly are in need of donationsof all assistive living and medical equipment.These include such items as wheelchairs, walkers,commodes, bathtub grab rails, tub seats, transferbenches, children’s wheelchairs, and other spe-cialty equipment. Wheelchairs and other itemsspecifically designed for children are in particu-larly high demand because children outgrow theirequipment so quickly.

The need for equipment continues to grow. Forexample, while 8,036 people borrowed equipmentin 2005, that number increased to 10,023 in 2011.And in 2012 it rose again, to 11,360 people. Needfor this service is increasing an average of 12 per-cent to 15 percent each year.

How it works

Unwanted durable medical equipment can bedonated at any of the drop-off donation centerslocated at our 29 retail stores throughout thestate, and it will get funneled to our equipmentloan program. All donated equipment is cleaned,reconditioned, and sanitized. If we cannot utilizean item in our program, we either recycle the rawmaterials or donate the item for use overseas.

Because post-surgery recovery typically lasts sixto eight weeks, it is our policy to loan equipmentfor two months at a time. Wheelchairs are in highdemand; as soon as one is returned by a bor rowerit is cleaned and sanitized, checked to ensure it stilloperates safely, and sent out on loan again.Happily, so many crutches and canes are donatedthat, at this time, we are able simply to give themaway to those in need.

Who benefits?

Most borrowers are over the age of 61, female,and have an acute medical need such as recover-ing from surgery. Based on what it would cost to buy the medical equipment we loan,Goodwill/Easter Seals estimates that this loan pro-gram saves Minnesotans more than $1 million a

year. It also saves taxpayerdollars, which help fundMedicare. One metro areaphysical therapist who regu-larly refers patients to ourloan program tells us, “Theprogram makes a big, big dif-ference. My clients who are

on Medicare are not able to get all their needs metthrough their coverage.”

In addition, borrowing equipment that will beneeded permanently allows the person whoneeds it to start using it while awaiting insurancecoverage approval to purchase their own equip-ment. And for someone who must use equipmentbut isn’t sure how long it will be needed, the loanprogram saves him or her money by not having to invest in equipment that may turn out to beneeded for two months or less.

Everyone benefits

If you no longer need a piece of durable medicalequipment, donate it. Donation benefits the donorbecause it is typically tax deductible.

If you do need a piece of durable medical equip-ment, borrow it.

To inquire about equipment availability, call one ofthe following numbers:

• St. Paul (651) 379-5922

• St. Cloud (320) 654-9527

• Willmar (320) 214-9238

• Rochester (507) 287-8699

To learn more, visit www.goodwilleasterseals.org

A helping hand during recuperationGoodwill/Easter Seals Minnesota’s medical equipment loan program

P E R S P E C T I V E

I

If you no longer need apiece of durable medical

equipment, donate it.


You call it

“reminding mom to take her pills.”

You or someone you know may be a caregiver. WhatIsACaregiver.org

We call it caregiving.

Dr. Maloney is a board-certified family physician who develops educational programs on Lyme disease. She is the president of Partnership for Healing andHealth, Ltd., a medical information company based in Wyoming, Minn.

How does someone contract Lyme disease? Deer ticks infected with bacteria that cause Lyme disease transmit that disease to people through their bite.Congenital infections, which are uncommon, occur when the bacteria pass frominfected pregnant women to their unborn children.

Tell us about the symptoms of Lyme disease. Lyme disease produces awide variety of symptoms that differ from person to person. Symptoms tend tocome and go with variable intensity. More symptoms may develop the longer anindividual is untreated.

The hallmark of early Lyme is a rash that appears two to 30 days after a tickbite and may be accompanied by influenza-like symptoms. The rash commonlyappears as a solid reddish oval that expands and then shrinks over several weeks.The classic “bull’s-eye” rash occurs in less than 20 percent of all cases. Most impor-tantly, data from the Centers for Disease Control and Prevention demonstrate that30 percent of patients never have the rash. For this reason, those who live in or whohave visited areas where Lyme disease has been reported should seek treatment forLyme disease if they develop flu-like symptoms.

How is it diagnosed? Diagnosis is based on a person’s risk of exposure toinfected ticks, symptoms, and physical exam findings. In symptomatic pa tients,blood tests that detect antibodies to the bacteria support a clinical diagnosis ofLyme disease, but negative results cannot rule it out because antibodies may beabsent. Early in the disease the body hasn’t had time to make antibodies, which iswhy antibody testing is inappropriate at this stage.

What happens if Lyme disease is untreated? Untreated infection maycause many problems, such as severe and persistent fatigue. Sixty percent of thoseinfected experience recurrent episodes of arthritis. Some experience heart rateabnormalities. These problems are readily identified and treated. Nervous systemproblems are also common but often go unrecognized. Untreated Lyme disease canalso cause, meningitis, nerve pain, diminished sensation, balance difficulties, Bell’spalsy, visual problems, sensitivity to light and/or sound, fevers, chills, headaches,neck stiffness, numbness/tingling, trouble sleeping, and new onset of depression,anxiety, or mood swings. Many people with untreated infection report persistentdifficulty with memory, thinking, and concentrating.

What can be done to reduce the risk of contracting Lyme disease?Avoiding deer ticks entirely prevents Lyme disease but when that’s not possible, beaware of potential tick exposure, use tick repellents and insecticides while in tickhabitat, and promptly remove ticks. Stay in the center of hiking trails; avoid fallenlogs and long grasses. Before going outside, apply insecticides and repellents. Applyinsecticides containing permethrin to clothing, hats, boots, and gear to kill ticks out-


1 0 Q U E S T I O N S

Photo credit: Bruce Silcox

Lyme diseaseElizabeth Maloney, MD

right. Repellents make ticks leave treatedareas before biting; DEET and picaradin aretwo repellents that can be applied to unbro-ken skin. BioUD is a natural repellent for useon gear and skin. Per form body-wide checksfor the tiny tick daily while in tick habitatand again after leaving it to find and removeattached ticks. Highly effective prevention uses awareness of poten-tial exposure, repellents and insecticides, and prompt tick removal.

In Wisconsin, the number of reported Lyme disease casesincreased dramatically between 1997 and 2007. Towhat do you attribute this? The increase in reportable cases isdue to greater exposure to ticks in their usual habitat, expansion ofthe areas where ticks can be found, and greater awareness of Lymedisease by the public and physicians. Exposure can happen in one’sown backyard. Minimizing exposure can be as simple as keepinggrass no more than 2–3 inches tall.

How is Lyme disease treated? Because Lyme disease is a bacte-rial infection, antibiotics are the primary treatment. The type ofantibiotic and the duration of treatment depend on sev eral factors,including the stage and severity of the disease and whether a personhas concurrent tickborne illnesses or medical conditions that mayweaken the immune system’s ability to combat the bacteria.

Why do professional opinions differ as to the best wayto treat Lyme disease? Most differences in opinion regarding

treatment result from a lack of information.Doctors don’t know which approaches arebest for different types of patients, and thereis very little evidence regarding what to dofor patients who remain ill. If your symptomspersist, seek a second opinion from a doctorwho is knowledgeable about tickborne dis-

eases and the diseases they mimic.

Why is there controversy about the possibility that thereis a chronic form of Lyme disease? Many within the medicalcommunity are unfamiliar with the scienti fic evidence. Cases of per-sistent infection in humans following antibiotic therapy are well doc-umented in medical literature. Antibiotics alone do not completelyeliminate infections; the immune system also plays a role. Researchershave discovered bacterial strains that tolerate certain antibiotics andhave identified several mechanisms that allow the bacteria to eludethe immune system. Multiple research studies of animals confirm thatantibiotic treatment in late-stage disease can be unsuccessful, result-ing in a persistent infection. While most patients will not becomechronically infected, claims that no one is are simply wrong.

What does the future hold for improving diagnosis ofLyme disease? A recently published scientific paper (InternationalJournal of Medical Sciences, 2013) described a new laboratorymethod for culturing, or “growing,” bacteria obtained from patients.This breakthrough may eventually help doctors diagnose Lyme diseaseearlier and determine when the infection has been fully cleared.


Highly effective preventionuses awareness of potential

exposure, repellents and insecticides, and prompt tick removal.

Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older.

Services• Outreach service and consultation with family or concerned persons• Evaluation and assessment for chemical dependency and/or mental health

issues completed by qualified professionals• Volunteer support for older adults who are chemically dependent• Support from peer volunteer counselors for older adults with mental health issues

ProgramsOlder Adult Chemical Dependency Primary Treatment ProgramA comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

Chemical dependency in older adults is hard to recognizeWe help them live a healthier life

Contact Us713 Anderson Ave., St. Cloud, MN 56303(320) 229-3762 • (800) 742-HELP toll-free

www.centracare.com(Search: Senior Helping Hands)


Chronic obstructive pulmonary disease(COPD) is the overall name for several conditions that make it hard to breathe.

It includes emphysema, chronic bronchitis, and asthma. Emphysema is caused by destruction of lung tissue. This traps air in the lungs and over-inflates them, leading to difficulty inhaling and shortness of breath. In chronic bronchitis, mucus is overproduced, gets infected, and clogs air-ways. Asthma’s hallmark is inflammation thatconstricts airways, making it difficult toinhale and exhale. People with COPD mayhave one or more of these conditions.

Who has it?

An estimated 4.1 percent ofMinnesotans, or 164,652 individuals,have COPD, the fifth-leading cause ofdeath in the state. It occurs equally inmen and women and is more likely to bediagnosed with increasing age.

Risk factors

Cigarette smoking is the main culprit, but exposureto lung irritants at home and in the workplace,including air pollution, chemical fumes, dust, andsecondhand smoke, also can be contributing factors.A less common cause is the inherited disorder alpha-1-antitrypsin deficiency, which can cause COPD in

someone who does not smoke and worsen the disease in someone who does.

Eighty percent of Minnesotans withCOPD smoke or used to smoke andunfortunately, one-third of them still do.It is important to note that risk of devel-oping COPD increases with the numberof years someone smokes and the numberof packs smoked. So the best way to mini-mize this risk is never to start smoking orto stop smoking if you currently do.

Symptoms and diagnosis

Symptoms can begin as early as someone’s late30s. Although COPD almost always develops

slowly over the course of years, symptoms often feel to the personwho has them as if they’ve appeared over the course of only monthsor even weeks. Because everyone is different, the severity of some-one’s shortness of breath may not correlate with the degree ofreduction in that person’s breathing capacity.

Diagnosis is typically accomplished by a simple, painless breath-ing test called spirometry. (Alpha-1-antitrypsin deficiency is diag-nosed by blood tests.) Many people attribute breathing problems togetting older or being out of shape. As a result, they delay consult-ing a doctor until they are having a lot of trouble breathing.

However, it’s important to consult a doctor if you have a coughor shortness of breath that persists.Although COPD can’t be cured, initi-ating treatment promptly helps controlsymptoms, slows the rate of decline inbreathing function, and improves aperson’s quality of life.

Treatment

It’s tough to quit smoking. If you needhelp quitting, talk to your doctorabout medication and nicotine replace-ments that support tobacco cessation.In addition, research shows that smokers who use phone counselingare more likely to quit than those who don’t use phone counseling.Everyone in Minnesota can take advantage of free phone counselingfor smoking cessation. This support is typically covered by health

P U L M O N O L O G Y

Chronic obstructive pulmonary disease (COPD)

How to handle it

By Amit Chandra, MD

The best way to minimize thisrisk is never tostart smoking

or to stop smoking if youcurrently do.

insurance and is also available to those without health insurancethrough QUITPLAN (see Resources).

Self-care

1. Exercise. Poor physical condition worsens shortness of breath. Everyone with COPD can benefit from regular physicalactiv ity; a person’s level of activity will vary according to thesever ity of his or her condition.

2. Pulmonary rehabilitation. COPD sufferers who become shortof breath when walking at their own pace on level groundshould engage in pulmonary rehab therapy programs, offeredthrough many hospitals. During therapy, individuals participatein regular, monitored exercise. This helps them learn to gaugewhen shortness of breath is acceptable and when it poses unnec-essary risks. It teaches breathing techniques to help them getthrough episodes of shortness of breath, and also includes aneducational component that helps individuals understand andmanage life with COPD.

3. Use medication properly. Medications help reduce symptoms,reduce frequency and severity of flare-ups, and improve overall health and exer-cise tolerance. People with milder COPDmay use only one inhaler on an as-neededbasis. Those with more advanced COPDmight use one or more medications on aregular basis. Steroid pills (prednisone)may be prescribed for flare-ups or forregular use. Supplemental oxygen alsomay be prescribed. It is vital to have your

doctor explain the role of each COPD medication and to followproper technique for using your inhaler(s).

4. Learn about your equipment. Nebulizers, oxygen delivery systems,and secretion-clearance devices are some of the equipment used bypeople with COPD. Understanding how to use equipment correc -tly, how to clean and maintain it, what to expect from it, and howto contact the equipment supplier with questions is essential. Thisinformation can be overwhelming when first presented, so it ishelpful to have a family member present during instruction.Oxygen delivery systems are not “one size fits all.” They eachhave different capabilities so the only way people can ensure theyare receiving enough oxygen to meet their needs is to have theamount of oxygen received tested while using the oxygen deliverysystem at home. Testing is done with an oximeter, a noninvasivedevice that measures the amount of oxygen in a person’s bloodwithout requiring a blood sample. Some people choose to measurethis while they perform different activities so that they can adjustthe amount of oxygen they consume accordingly.

5. Prevent infections. Respiratory infections often trigger COPDflare-ups. Get influenza and pneumococcal vaccinations, clearmucus from your lungs, use good hand-washing and generalhygiene practices, and avoid sick people. You know your bodybest, so it makes sense that you would be the first to identifyearly signs of a flare-up. Signs can include a change in theamount, consistency, or color of your secretions. Another signcan be a significant increase in shortness of breath that differsfrom your normal shortness of breath, especially if it is notrelieved by using your inhalers. Ask your physician to help you to

develop an action plan to identify early signs of an infection orflare-up and medications you can use to quickly address thosesymptoms.

6. Realize that you are not alone. Having a chronic disease can feeloverwhelming and test your coping skills. Getting your familyinvolved in your care and knowledgeable about COPD is impor-tant, as is interacting with others who have chronic lung disease.Better Breathers Clubs are support groups for adults with chroniclung disease, feature speakers on respiratory topics, and offeropportunities for learning and camaraderie with others who caneasily relate to your concerns and share information about howthey have tackled problems.

Armed with proper education about your condition, you CANlive a full life with COPD.

Amit Chandra, MD, is a board-certified pulmonologist who practices atRespiratory Consultants, PA, in Robbinsdale.


You may have CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Qualified volunteers will receive study-related testing and study drug at no cost and compensation for time and travel.

There will be 10 office visits over approximately a 15 week period.

www.CRIminnesota.com 612-333-2200 x 5

TO QUALIFY: Age 40 years or older Smoker or Ex-Smoker Symptoms such as: increased phlegm,

cough and shortness of breath

Volunteers needed to participate in a research study testing an investigational drug for COPD.

Harold Kaiser, MD Philip Halverson, MD Gary Berman, MD Allan Stillerman, MD Richard Bransford, MD Hemalini Mehta, MD

Mary Anne Elder, FNP-C, Research Manager

Offices located in Minneapolis and Plymouth

Clinical Research Institute Since 1985

Resources• QUITPLAN: Free, one-on-one telephone counseling for

quitting smoking. (888) 354-7526. www.quitplan.com• To find Better Breathers Clubs and Pulmonary Rehabilitation

Programs, or to be added to the mailing list for the freeairLINES newsletter, contact (651) 227-8014/(800) LUNGUSA or visit www.lungmn.org

• LungHelp Line: Speak with a respiratory therapist, nurse, ortobacco cessation expert who will answer your lung healthquestions. (800) LUNG USA. www.lunghelpline.org

Everyone with COPDcan benefit

from regularphysical activity.

There is a lot of talk about corticosteroids in the media these days, usually focusing on theshorthand name for this class of drugs, which is “steroids.” Typically the discussion is aboutperformance-enhancing products used by athletes, but in truth, this class includes a variety

of drugs that are used for medicinal purposes. Steroids have a wide range of use because they areman-made versions of the hormone cortisol, which plays a role in many bodily processes, includingresponse to physical stress, maintaining blood pressure, and ensuring biological equilibrium. While

the effects of corticosteroids on the body range widely, membersof this drug class are used mainly for decreasing inflammationand for inhibiting processes that trigger the immune system. Thisarticle will discuss common forms of drugs in this class, theiruses, and their side effects.

Topical

“Topical” means that something is applied to the skin, and cor-ticosteroids have been delivered to the body in this manner formore than 50 years. Topical corticosteroids exist as ointments,creams, and lotions. Because ointments stay on the skin longer thando creams and lotions, this permits longer contact between drug and skin, thus enhancing absorptionof the drug by the skin. Topical corticosteroids are used to treat inflammatory skin conditions suchas eczema, psoriasis, and atopic dermatitis. The drug decreases the size of a skin lesion by suppress-

ing the allergic reaction, which is an immune response that makes thelesion visible.

All topical steroids can induce skin atrophy, or thinning of theskin. This risk is increased by using higher potency topical steroids forprolonged duration and by use in older patients who already have age-related thin skin. Permanent skin atrophy from topical corticosteroids is not a common problem if the drugs are used properly. However, in-creased duration of use can cause permanent stretch marks, usually onthe upper inner thighs, under the arms, and in elbow and knee creases.

Oral

Oral corticosteroids are available in the form oftablets, capsules, or syrups. These forms aredigested and the drug is absorbed into thebloodstream. The drug can then travelthroughout the entire body, which meansthat it’s called a “systemic” drug. The factthat orally administered steroids are sys-temic gives them the potential to affect theimmune system and reduce inflammation inall different regions of the body. The amountof suppression from the steroid depends on how much exposure agiven part of the body has to the drug, which is determined primarilyby the size of the dose. The anti-inflammatory effect of the steroidprednisone, for example, is used to help manage the pain and jointdestruction caused by inflammation in autoimmune conditions such as rheumatoid arthritis and systemic lupus erythematosus. If the doseis increased, the same immunosuppressive property of this drug classcan be used to help an organ recipient prevent rejection of the trans-planted organ.

D R U G C L A S S

Corticosteroids

SMU offers bachelor completionand master’s programs in the

health & human services areas.

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Advance your career inhealth & human services

Graduate School of Health & Human Services

Powerful inflammation-fightersBy Anita Sharma, PharmD, and Chrystian Pereira, PharmD, BCPS


Risk of negative side effects of oral corticosteroids increases thelonger the drug is used and the greater the dose that is used. Long-term use of oral corticosteroids can cause the body to produce lessnatural steroid, thereby decreasing the body’s ability to respond tophysical stress. Additionally, prolonged suppression of the immunesystem increases the risk of infections. Long-term usealso has been associated with decreased bone density.The effects of systemic corticosteroids on the eye condi-tion called open angle glaucoma are mild, and are morelikely to develop after a year or more of systemic corti-costeroid treatment. Glaucoma is associated most oftenwith longer-acting oral steroids, such as betamethasoneand dexamethasone, and less often with immediate- acting steroids like prednisone and with short-actingsteroids such as hydrocortisone and cortisone. The ele-vated eye pressure that can cause glaucoma is usually reversible afteran individual stops using the drug.

Other common side effects associated with oral corticosteroid useinclude increased appetite and resulting weight gain, increased bloodsugar levels and blood pressure, and trouble sleeping. Not all patientsexperience these side effects, and how often side effects occur variesfrom one patient to another. Techniques to minimize side effects oforal corticosteroids include using them for the shortest duration pos-sible, taking the smallest dose possible, and monitoring for expectedside effects. When long-term use is needed, consider additional cal -

cium supplements to moderate the risk ofdecreased bone density.

Inhaled

Inhaled corticosteroids are a valuable tool inthe control of asthma, which is a chronic

inflammatory disorder. Corticosteroids releasedby inhalers reduce inflammation, thereby opening

the lung’s air passages. In the process, these drugsalso decrease the amount of mucus inside airways, pro-

duced by the body as part of the inflammatory response. De creasinginflammation and the amount of mucus makes it easier for oxygen tomove through the airways.

In its inhaled form, most of this drug stays in the lungs and onlyvery small amounts of it are absorbed into the body. Therefore, thesemedicines do not tend to cause the more serious long-term side effectsassociated with oral forms of this drug class. Research published inthe New England Journal of Medicine in 2006 assessed effects ofinhaled corticosteroids on children and their physical developmentlater in life. The researchers reported that even though using inhaledcorticosteroids may slow a child’s growth when the child first startsusing inhalers, the child typically grows to a normal height by adult-hood. In general, inhaled corticosteroids are well tolerated and safe atthe recommended dosages.

Injected

Injectable steroids may be prescribed for patients who do not respondto or tolerate other anti-inflammatory therapies, and can also beinjected directly into joints to reduce inflammation. For example,injection of the steroid cortisone directly into a shoulder is sometimesperformed to treat so-called “frozen shoulder,” arthritis, and rotatorcuff injury. However, use of this type of therapy is limited; repeatedinjections into a joint can damage that joint’s connective tissue and

can cause skin tobecome thin at thepoint of repeated injection. It is also possible to have steroids traveloutside the joint and cause other problems, similar to side effectsassociated with oral corticosteroids. However, the extent of this

systemic influence varies among patients.

Important tool

Corticosteroids remain an important class of drugs fortreating many types of inflammatory conditions, andapplications continue to expand. For example, a neworal corticosteroid, Uceris (budesonide), was approvedby the Food and Drug Administration in February 2013for the treatment of ulcerative colitis. Uceris’ effects arelocal and target predominantly the colon. Patients using

this drug should avoid grapefruit juice because it can increase levelsof Uceris in the blood and therefore magnify its effects.

Corticosteroids have been an important part of health care treat-ment for decades, and generally have been used safely. The amount ofcorticosteroid, its form, and the duration of its use are all factors thatinfluence how the medication affects the body.

Make sure to discuss any plans to use steroids with your healthcare provider and consider both known benefits and cautions beforeextended or prolonged treatment.

Anita Sharma, PharmD, is a Pharmaceutical Care Leadership resident at theUniversity of Minnesota and at Smiley’s Family Medicine Clinic, Minneapolis.Chrystian Pereira, PharmD, BCPS, is an assistant professor in the Universityof Minnesota College of Pharmacy and a clinical pharmacist at Smiley’sFamily Medicine Clinic.


Do you have trouble using the telephone dueto hearing loss, speech or physical disability?

If so…the TED Programprovides assistive telephoneequipment at NO COST to those who qualify.

Please contact us, or have your patients call directly, for more information.

1-800-657-3663www.tedprogram.org

The Telephone Equipment Distribution Program is funded through theDepartment of Commerce Telecommunications Access Minnesota (TAM)and administered by the Minnesota Department of Human Services

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Make sure to discuss anyplans to usesteroids withyour health

care provider.

Breast cancer is the most common cancer among women,accounting for approximately 34 percent of female cancersdiagnosed in Minnesota, similar to the national average.According to the Minnesota Department of Health, about3,700 new cases of breast cancer are diagnosed inMinnesota women each year. (Breast cancer occurs inmen, too, but far less often. Any changes in a man’s chest

should prompt him to contact his health care provider.)Recently, the media has publicized women with a diag-

nosis of breast cancer who decided to prevent breast cancer inthe opposite, healthy breast by removing it. This procedure is

called contralateral prophylactic mastectomy. Also, there have been reportsof women who chose to remove both breasts before cancer was detected.This procedure is called bi la ter al prophylactic mastectomy. Such reports,plus conflicting screening recommendations publicized during the past fewyears, have produced confusion.

What should women know about screening for breast cancer? If awoman is diagnosed with it, what are her treatment options? Shouldshe consider removing both breasts? How can a woman minimize herrisk of developing this cancer?

Early detection of breast cancer

Let’s start with what we know: The sooner breast cancer is detected and treated, the greater a woman’s likelihood of survival.Mammography is the best method to find breast cancer at its earlieststage and has been shown to decrease death from breast cancer.

However, its benefits for women may differ depending on awoman’s age. For women ages 40–49, most major health organiza-tions have concluded that mammography’s survival benefits outweighits risks (which include false positive results) and recommend yearlymammograms for women 40–49.

In women 50–69, mammography’s benefits are more clear. Basedon evidence from many research studies, women ages 50–69 shouldhave annual mammograms.

In women age 70 and older, the role of screening mammographyin saving lives becomes less certain, perhaps because there are signifi-cantly fewer studies on mammography in older women. Most majorhealth organizations recommend that healthy women age 70 andolder schedule mammograms on a regular basis since breast cancerrisk increases with age. Mammography maintains success in earlydetection, regardless of a woman’s age. If there is any question aboutwhether a woman should continue getting screened, she should con-sult her primary physician.

Prophylactic mastectomy

When a woman is diagnosed with breast cancer, she and her surgeondiscuss her options. One is to remove the cancer and some surround-

Breast cancer screening

Detection, treatment, and prevention of breast cancer

By Annelisa Carlson, MD, MS,and Ellen L. Abeln, MD

W O M E N ’ S H E A L T HP

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In the next issue...

• Spinal fusion

• Nail salon safety

• Pancreatic cancerresearch


ing normal tissue, which is called a lumpectomy. Sometimes, lumpec-tomy is not an option because of the size or extent of the cancer.

If that’s the case, a woman typically elects to remove the entirebreast, which is called a mastectomy. Some women decide to removethe other breast at the same time, i.e., to have a contralateral prophy-lactic mastectomy.

Contralateral prophylactic mastectomy Why would someone consider removing a healthy breast? Women with cancer in onebreast may benefit from removing the healthy breast if they’re at

high risk of breast cancer.This includes those with an

underlying gene mutation suchas the BRCA1 or BRCA2 gene,which can be detected with thehelp of a genetic counselor rec-ommended by the woman’shealth care provider. It alsoincludes those who have addi-tional factors that make it hard-er to evaluate the healthy breastvia mammography or ultra-

sound. Such factors can include dense breast tissue or calcificationswithin the breast. Some women choose to remove the oppositehealthy breast for cosmetic reasons, believing it will increase the like-lihood that both breasts will look alike after surgical reconstruction.

Between 1993 and 2003, contralateral prophylactic mastectomyin the U.S. among patients with breast cancer on one side increasedby 150 percent. While this procedure has been shown to reduce therisk of developing cancer in the healthy breast, it may not actuallydecrease a woman’s risk of death from breast cancer.

In addition, in women with breast cancer that is detected at anearly stage, the risk of removing the opposite healthy breast may out-weigh the benefit. That’s because surgery to remove the healthybreast carries with it the risk of infection and other complicationsinherent in surgery. In other words, it may cause more harm to awoman to remove her healthy breast than it may help prevent herrisk of dying of breast cancer.

Overall, removing the opposite healthy breast is reported todecrease incidence of breast cancer in that healthy breast by nearly 95 percent. This procedure’s reduction of cancer risk is never 100 percent because there is always a small amount of residual breast tissue left behind following mastectomy.

A woman’s decision to remove the healthy breast should be made following consultation with the team of physicians caring forher during breast cancer treatment. This includes her surgeon, med-ical oncologist, radiation oncologist, and a genetics counselor, partic-ularly if the patient is young or has a strong family history of breastcancer. Women considering removal of the opposite breast shouldknow that one nonsurgical way to reduce the risk of breast cancer in


Breast cancer screening to page 19

Mammography has been shown to decrease death from breast cancer.

Women ages 50-69

should have

annualmammo-grams.

Winter can be a hard time. It’s tough to get out of the house.And sometimes, it can be lonely. Now is exactly the time to call SeniorsHelping Seniors in-home services. We’re like a friend who helps withlight housekeeping, small repairs, driving, shopping, cooking and more.

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Through Aug. 31 Anatomy Exhibit University of Minnesota presents Appliancesof Science: Anatomical Substitutionsthrough Time. Come learn about the historyof prostheses and rehabilitation through primary resources, text, instruments, andartifacts. Free. Call (612) 626-6881 formore information.Monday–Saturday, through Aug. 31, 8 a.m.–4:30 p.m., Wangensteen HistoricalLibrary, 5th Floor Diehl Hall Duels, 505 Essex St. S.E., Minneapolis

6 Multiple Sclerosis Acorda Therapeutics presents Gareth Parry,MD, as he discusses multiple sclerosis (MS)and how it can affect you or someone youcare for. Come join us for a free interactiveand educational program. Complimentaryfood served. To register or for more infor-mation, call (866) 397-8082.Monday, May 6, 12:15 p.m.–1:15 p.m.,50 Willey Hall, MPC Seminar Rm., 225 19th Ave. S., Minneapolis

9 Thyroid HealthMississippi Market Co-op presents SaraJean Barrett, ND, as she discusses thyroidhealth. Learn how sluggish thyroid functioncan impede overall health and what keynutrients are necessary for optimal thyroidfunction. Cost is $5 for co-op member/owners; $10 for nonmember/owners.Register at www.eventbrite.comThursday, May 9, 6–7 p.m., MississippiMarket Co-op, 1500 W. 7th St., St. Paul

18 Ataxia SupportThe National Ataxia Foundation offers thissupport group for people afflicted by ataxiaand their friends and family. Come andreceive support from others suffering fromthis same condition. No registration neces-sary. Call Lenore at (612) 724-3784 formore information.Saturday, May 18, 10 a.m.–12 p.m.,Langton Place, 1910 W. Cty. Rd. D,Roseville

18–19 Health ExpoMy Health and Wellness Expo is a two-dayevent featuring vendors, nonprofits, cityagencies, healers, and providers from all

over the country. Learn about a healthylifestyle and products that are available.Admission is free and open to all ages. Call (602) 625-3000 for more information.Saturday, May 18, 10 a.m.–5 p.m.,Sunday, May 19, 11 a.m.–4 p.m.,Minnesota State Fair Grandstand, 1265 Snelling Ave., St. Paul

20 Infant CPR Regina Medical Center offers a basic infantcardiopulmonary resuscitation class for parents and caregivers. No certification isgiven with this class. Free. Call (651) 404-1200 to register or for more information.Monday, May 20, 7–9 p.m., ReginaMedical Ctr., Family Birthing Ctr., 1st FloorClassroom, 1175 Nininger Rd., Hastings

23 Caregiver SupportAllina Health presents this free caregiversupport group. Receive emotional supportfrom peers and learn about the resourcesand activities available to caregivers. Noregistration required. Call (763) 236-8910for more information.Thursday, May 23, 3:30–5:00 p.m., Mercy Hospital, 4050 Coon Rapids Blvd.,Coon Rapids

28 RESOLVE InfertilityLakeview Health presents a support groupfor those struggling with infertility. Come to share your experiences and receive support. This group meets the fourthTuesday of every other month. Free. Noregistration required. Call (651) 430-1758or (651) 253-2746 for more information.Tuesday, May 28, 7–8:30 p.m., LakeviewHospital, 927 Churchill St. W., Stillwater

28 Disability WorkshopPACER Center presents Lori Guzmàn, JD, as she discusses what families should con-sider when planning to protect and assist achild with disabilities in the transition toadulthood. Learn about guardianship andconservatorship. Free. Register atwww.pacer.org. Call (952) 838-9000 for more information.Tuesday, May 28, 6:30–8:30 p.m., PACERCtr., 8161 Normandale Blvd., Minneapolis

Send us your news:We welcome your input. If you have an event youwould like to submit for our calendar, please sendyour submission to MPP/Calendar, 2812 E. 26thSt., Minne apolis, MN 55406. Fax submissions to(612) 728-8601 or email them to [email protected]. Please note: We cannot guaranteethat all submissions will be used. CME, CE, andsymposium listings will not be published.

America's leading source of health

information online18 MINNESOTA HEALTH CARE NEWS MAY 2013

May Calendar

Did you know that skin cancer is the mostcommon form of cancer in the UnitedStates? Over 2 million new cases of skincancer are diagnosed in the U.S. each year,comprising about half of all other types ofcancers combined. It is estimated that oneAmerican dies every hour from skin cancer.

Skin cancer is one of the most preventa-ble forms of cancer, yet the incidence ratefor it is rising while the incidence rate ofother common cancers is falling. For thesereasons, the National Council on Skin Can-cer Prevention has designated the Fridaybefore Memorial Day “Don’t Fry Day.”

There are several steps that you cantake to protect your skin this summer: • Seek shade when possible.• Limit the amount of time in direct sun,

especially from 10 a.m. to 4 p.m.• Wear protective clothing: sunglasses, long

sleeves, and a wide-brimmed hat.• Avoid intentional tanning and sunburning.• Wear sunscreen of SPF 15 or higher on all

skin that isn’t covered, even on cool orcloudy days.

For more information on Don’t Fry Day or skin cancer, visit: www.skincancerprevention.org

22 Minnesota Cancer AllianceMinnesota Cancer Alliance hosts a meeting so participants can learn about Minnesota’scancer burden, current cancer legislativeactivities, and discuss future Alliance actions.Free. Register at www.mncanceralliance.orgContact Heather [email protected] for information.Wednesday, May 22, 1–5 p.m., Wilder Foundation, 451 Lexington Pkwy. N., St. Paul

Don’t Fry Day

the healthy breast is by using medications such as Tamoxifen or aro-matase inhibitors.

Bilateral prophylactic mastectomy If a woman has a family his -tory of breast cancer, she should be evaluated to see if she carriesthe breast cancer gene BRCA1 or BRCA2. Women with this geneticpredisposition to breast cancer may wish to talk with their physi-cian about undergoing removal of both healthy breasts beforebreast cancer develops. This procedure is called a bilateral prophy-lactic mastectomy. Use of medications such as Tamoxifen or aro-matase inhibitors by high-risk women who have not yet been diag-nosed with breast cancer has been shown to decrease their risk of afuture diagnosis of breast cancer.

The type of surgical procedure chosen by a woman diagnosedwith breast cancer or with a high risk of developing breast cancer is ahighly personal decision. A woman should be aware that all membersof her health care team can give her valuable information that canhelp her make the best decision for her own unique circumstance.

How to reduce risk of breast cancer

The American Cancer Society recommends the following to reducethe risk of developing breast cancer:

• Maintain a healthy body weight throughout life.

• Practice portion control; avoid excessive weight gain.

• Engage in at least 150 minutes of moderately intense physical activ-ity or 75 minutes of vigorous physical activity each week, prefer-ably spread throughout the week.

• Limit sedentary behavior such as sitting, watching television, and

other screen-based entertainment.

• Consume a healthy diet, emphasizing plant-based foods.

• Limit alcohol intake.

Women should also determine their personal risk for breast can-

cer by learning their family health history. If a woman’s mother orsister was diagnosed with breast cancer before age 40, or if she hasmultiple relatives with a diagnosis of breast and/or ovarian cancer,she should talk with her physician about being evaluated for a geneticpredisposition to breast cancer.

Despite controversy surrounding breast cancer care, womenshould be confident that their health care team is always availableto help them navigate information regarding diagnosis and treat-ment. We have the tools to detect breast cancer early, and we havethe ability to treat women successfully. Schedule your mammogramtoday.

Annelisa Carlson, MD, MS, is a breast-imaging fellow at the University ofMinnesota. Ellen L. Abeln, MD, is a board-certified radiologist and is themedical director of the Breast Center of Suburban Imaging in Coon Rapids, a facet of Suburban Radiology.

Breast cancer screening from page 17

The sooner breast cancer is detected and treated, the greater a woman’s likelihood of survival.


952-886-7588nwhealth.edu/yourhealth

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B E H A V I O R A L H E A L T H

Pediatric bipolar disorder

Vigilance is the key to management

By Joel V. Oberstar, MD

It’s estimated that between 0.5 percent and 5 percent of youthin the U.S. suffer from the chronicmental health condition calledbipolar disorder. The good news is that with diagnosis and treat-ment these youngsters can leadproductive and satisfying lives.

Where do you turn when your child is

struggling emotionally?

Help is near. The Children’s Mental Health Clinic at St. David’s Center provides the treatment and strategies families need to move forward.

Learn more: stdavidscenter.org/mentalhealth952.548.8700

What is it?

Previously referred to as manic-depressivedisorder, bipolar disorder is an illness inwhich patients suffer from varying “moodepisodes.” At times they are extremelydepressed, while at other times their moodand energy are quite elevated. It is likelycaused by a variety of factors that includegenetics and life stressors, and exists in threeforms: bipolar I disorder, bipolar II disorder,and bipolar disorder NOS.

Diagnosing bipolar illness

A diagnosis of any form of this condition ismade by identifying a mix of one or more ofthe following mood episodes.

A major depressive episode is a period of severe depression lasting two weeks orlonger.

A manic episode is characterized bymania. Mania consists of euphoria and highenergy and can include psychosis, which ischaracterized by defective contact with real -ity and can be accompanied by hallucina-tions or delusions. Manic episodes typicallylast one week or longer.

Hypomania is less intense than maniaand typically lasts less than one week.

A mixed episode typically lasts one weekor longer and involves a patient meeting cri-

teria for both manic and major depressive episodes. Patients with bipolar I disorder are those who have experienced

at least one manic or mixed episode. Those with bipolar II disorderhave experienced at least one episode of major depression and oneepisode of hypomania. Patients who experience multiple symptoms ofone of these four episodes at varying times, but whose symptoms do

not meet full criteria for I or II, aredescribed has having “bipolar disor-der not otherwise specified,” or bipo-lar disorder NOS.

Diagnostic challenges

While the expression of bipolar illnessin adults is frequently quite apparent,making the diagnosis in youngsters isoften much more challenging becausemany kids do not meet full criteria fora diagnosis of bipolar I disorder orbipolar II disorder. One reason is that

a child or adolescent may not exhibit symptoms of sufficient dura-tion. Additionally, many young patients have a mix of symptoms thatare not easily classified into one specific illness.

Consider a 10-year-old boy with a history of fetal alcohol expo-sure, who was adopted from an orphanage (where he may have expe-rienced neglect, abuse, or both) at age 5, and who exhibits dramaticmood swings from rageful aggression to weeping hopelessness. Doeshe have pediatric bipolar disorder, a fetal alcohol spectrum disorder,post-traumatic stress disorder, some combination of these conditions,

or something completely different? Suchcases can be quite difficult to diagnoseaccurately.

For other kids, especially adoles-cents, a diagnosis of bipolarity cansometimes be crystal clear. Consider a16-year-old male with no previous psy-chiatric history who, after a heateddebate with a classmate, slips into afive-day period of sleeplessness, racingthoughts, rapid speech, agitation, andgrandiose delusions of being JesusChrist. His behaviors are so dramaticthat he requires hospitalization in apsychiatric facility. He has no history ofusing drugs or alcohol and has a pater-nal uncle whom every family membercharacterizes as having classic bipolar Idisorder. This patient undoubtedly isexperiencing an acute manic episode. Inthis case, a diagnosis of bipolar I disor-der is quite appropriate.

Accurate diagnosis is the first step

Parents who wonder if their child’smood or behavior suggests bipolar


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Pediatric bipolar disorder to page 25

Mood EpisodeSymptoms

Major DepressiveEpisode

Sadness Irritability

Hopelessness

Suicidal thinking

Manic EpisodeGrandiosity

Euphoria

Pressured speech (rapid, urgent, difficult to interrupt)

Flight of ideasDecreased need forsleep

Hypomanic EpisodeIncreased goal-directedactivityDecreased need forsleep

Highly productive behavior

Irritability

Many patientswith chronic

bipolar illnessgo on to leadvery fruitful,fulfilling, and

productive lives.


These and other work-related questions confront people who already may feel overwhelmed by juggling cancer treatment in addition to the practical and legal complications that arise as a direct result of their cancer diagnosis. Although a diagnosis of cancer can feel overwhelming,employees need to know their rights in order to advocate effectively forthemselves in the workplace.

Legal protectionThree main laws protect Minnesota cancer survivors in the work-place: the Americans with Disabilities Act (ADA), the MinnesotaHuman Rights Act (MHRA), and the Family Medical Leave Act(FMLA). It’s easy to get lost inthe alphabet soup of variouslaws, but it’s important for cancersurvivors to understand what eachlaw is designed to do. The ADA

Can I be fired because I have cancer?

My supervisor said I’d better come back full time when my leave is up or else there won’t be a job to come back to.Is that legal?

I haven’t told anyone at work that I’m receiving cancer treatment. It’s my business; why should they know?Cancer

in the workplaceKnow your rights

By Lindy Yokanovich, Esq.

P O L I C Y

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and MHRA aim to keep people with disabilities in the workplace byproviding reasonable accommodations and protections against dis-crimination. The MHRA provides additional protections beyondwhat the federal ADA would otherwise provide to Minnesotaemployees. The FMLA provides employees with job-protected leavethat allows them to step out of the workplace to care for themselvesor a loved one with a serious health condition.

Staying on the job Protections against discrimination The ADA andthe MHRA are similar laws that do two veryimportant things to protect cancer survivors inthe workplace. The first is to provide protec-tions against discrimination by an employer onthe basis of an employee’s disability. Under the

ADA, “disability” is defined as (a) a physical or mental impairmentthat substantially limits one or more major life activities, (b) a recordof such an impairment, or (c) being regarded as having such animpairment.

People diagnosed with cancer will almost always meet these laws’definition of having a disability because “major life activity” includes“the operation of a major bodily function, including but not limitedto … normal cell growth …” Since cancer is defined as “uncontrolledgrowth and spread of abnormal cells,” it is hard to imagine a situa-tion in which a person diagnosed with cancer would not be founddisabled according to the ADA and MHRA.

Individuals whose cancer is in remission are also protected.That’s because the ADA states that an impairment which is “episodicor in remission” is disabling if it substantially limits a major lifeactivity when the impairment is in its active state. The ADA appliesthese protections to employees of employers with 15 or more employ-ees, but in almost every circumstance the MHRA extends them to allMinnesota employees.

Providing reasonable accommodation The second protection theADA and the MHRA provide for cancer survivors is to requireemployers to provide “reasonable accommodation” to employeesunless doing so would cause the employer “undue hardship.”Generally, this means modifying the work environment to enable aqualified disabled individual to perform essential functions of the job.Reasonable accommodations may include: adjusting work schedules,reallocating marginal tasks to another employee, allowing periodicbreaks throughout the day to take medication, leave for medical

appointments, or leave to seek or recuperate from treatment. Unduehardship typically is interpreted as causing the employer significantdifficulty or expense and is determined on a case-by-case basis. Boththe ADA and MHRA require only those employers with 15 or moreemployees to provide reasonable accommodation.

Arriving at a reasonable accommodation requires both employeeand employer to engage in an informal “interactive process.” Theemployer isn’t required to accept the employee’s proposal unquestion-

ingly. However, the two must work together to try to arriveat a workable solution. It’s prudent for the employee tomaintain a written record of these interactions. Thisincludes email to the employer requesting a meeting andthe reason for it, and follow-up email to the employer reit-erating what was discussed and agreed upon, including cal-endar dates agreed upon for employee absences.

Telling a supervisor about one’s cancer can be frighten-ing. However, an employee who does not inform his or heremployer of a disability or the need for reasonable accom-modation is not eligible for ADA/MHRA protection.

For example, an employee may think that the best wayto keep his job is to schedule radiation treatments aroundhis regular workday and not discuss his need for a reason-able accommodation with his employer. All too often,

though, this actually works against him. Fatigued by treatment, theemployee may think he is still meeting job expectations. However, hisemployer notes that his job performance is slipping and decides toterminate the employee for poor performance. In this case, because


Cancer in the workplace to page 24

Where to get help Cancer Legal Line coordinates pro bono (i.e., free) legal services for Minnesotans affected by cancer and who otherwise would not be able to afford an attorney’s help for legal issues that accompany a cancer diagnosis. Cancer Legal Line provides legal assistance in the following areas:

• Insurance (COBRA, health insurance coverage denials, STD/LTD)• Housing and Financial (foreclosure, eviction, debtor/creditor,

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the employee did not tell the employer of his disability and his needfor a reasonable accommodation, and because the employer did notknow about the disability, the employee is not protected by the ADAor MHRA.

Time off FMLA leave permits 12 weeks of unpaid, job-protectedleave in a 12-month period for employees to care fortheir own “serious health condition” or that of theirspouse, parent, or child. (Domestic partners are notincluded in FMLA leave protection. Some employersprovide job-protected leave allowing an employee tocare for a partner, although it’s not legally required.) To qualify, all of the following conditions must be met:

(1) The employer must employ 50 or more employeesfor 20 or more calendar workweeks in the currentor preceding calendar year.

(2) The employee must have been employed for at least12 months by the employer from whom leave isrequested.

(3) The employee must have worked at least 1,250hours during the last 12 months.

(4) The employee works at a location at which theemployer has 50 employees within 75 miles.

FMLA defines “serious health condition” as “anillness, impairment, or physical or mental conditionthat involves … inpatient care … or continuing treat-

ment by a health care provider.” Most forms of cancer typically sat -isfy this requirement. If an employee has, as a benefit of employment,paid time off in the form of vacation time, sick leave, or other paidtime off, the employer may require the employee to take that paid

leave concurrent with the FMLA time. In that case, if an employee has two weeks of paid

vacation and one week of paid sick leave, he or she stillis entitled to only 12 weeks of job-protected leave. The employee would have three weeks paid leave (twoweeks of paid vacation plus one week of paid sickleave) and nine weeks unpaid, not three weeks of paidleave followed by 12 weeks of FMLA. The employermay require certification from the employee’s healthcare provider to support the request for time off.FMLA leave may be taken in one 12-week block oftime or intermittently as needed.

Often, cancer patients who use their 12 weeks con-secutively in one block of time find they need addition-al time off due to their cancer diagnosis or treatment.At this point, additional unpaid time from work mightbe requested as reasonable accommodation under theADA/MHRA. Whether or not such a request is granteddepends entirely on whether it would be an “unduehardship” on the employer’s business.

Lindy Yokanovich, Esq., is the founder and executive director of the nonprofit organization Cancer Legal Line. For more information, visit www.cancerlegalline.org or call (651) 472-5599/(888) 231-6942.

Cancer in the workplace from page 23


An employeewho does notinform his or

her employer isnot eligible forADA/MHRAprotection.

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illness should consult their child’s primary careprovider to explore whether the child’s symptomsindicate the presence of mental illness. Because pedi-atric bipolar disorder is quite rare compared withother illnesses (anxiety, depression, and ADHD, forexample, are much more common), considerationmust be given to identifying what is causing thechild’s symptoms. Referral to a mental health pro-fessional such as a psychologist or child and adoles-cent psychiatrist may be appropriate depending onthe primary care provider’s findings.

Early diagnosis and treatment are likely to resultin improved outcomes. Patients who are diagnosedearly and accurately are more likely to haveimprovements in their mood, behavior, and socialfunctioning than those who go undiagnosed anduntreated. Additionally, early attention to psychi-atric symptoms may allow early interventions thatmake it easier to manage the course of the illnessand to prevent relapses; this can improve the child’s—and family’s—quality of life.

Treatment

Treatment guidelines from the American Academy of Child andAdolescent Psychiatry suggest that a multipronged approach of care-fully selected and monitored prescribed medication, psychotherapy,and education helps youth and their families manage bipolar illness.Typically, after a patient is diagnosed with bipolarity, he or shespends several months receiving psychotherapy and, if appropriate forthe patient’s age, education about the importance of chemical sobrietyand maintaining healthy sleep patterns.

Then, the patient’s symptoms are monitored to determine if thedose of medication can be reduced or discontinued. Close monitoringof symptoms by the patient, family, and physician is critical, becauseonce a youngster has experienced one mood episode he or she is pre-disposed to have another one. Some patients will not experienceanother episode for years, while others may slip into “rapid cycling,”where they experience four or more episodes within one year.

Part of learning to live with bipolar disorder is learning to recog-nize what can trigger a mood episode. Triggers can include sleep dis-turbance, such as staying up all night studying for final exams. Othertriggers can be a breakup with a boyfriend or girlfriend, or abusingstimulants like Adderall XR, which is sometimes prescribed for treat-ment of ADHD.

Prognosis

As with other chronic health conditions, patients living with bipolardisease must be vigilant to avoid flare-ups of their illness. If a flare-upoccurs, the youngster’s physician may recommend resuming medica-tion that had been stopped, or increasing the youngster’s existingdose of medication. Some youth benefit from long-term maintenancemedication.

Youth who are diagnosed with bipolar disorder should see theirphysician regularly throughout their childhood. In addition, the accu-racy of the diagnosis should be reassessed as the child developsbecause relatively recent research indicates that brain development is

nonlinear and likely continues into a person’s 20s.Consequently, some patients may no longer experi-ence symptoms of a mental illness as they move fromchildhood to adolescence and into adulthood.

Nonetheless, many patients with chronic bipolarillness can and do go on to lead very fruitful, fulfill-ing, and productive lives. As a local example, televi-sion meteorologist Ken Barlow revealed in the fall of2012 that he had been diagnosed five years earlierwith bipolar I disorder. In talking about his experi-ence with the disorder, he said, in an interview withthe Pioneer Press, “My episodes are pretty muchunder control these days. I have good days and baddays just like anybody. I take my medication reli-giously. I go to my doctors. I get my blood tested. Ido what they tell me to.”

Those of us working with children and adoles-cents suffering from mental illness are reminded everyday that children have a tremendous capacity forresilience and growth. Kids from all walks of life whoexperience a range of mental illnesses have the poten-

tial to live happy, successful, and productive lives.

Joel V. Oberstar, MD, is CEO and chief medical officer of PrairieCare, an organization providing inpatient psychiatric care to children and adoles-cents and outpatient care to patients of all ages at three locations in theMinneapolis–St. Paul area. He is board-certified in psychiatry and in childand adolescent psychiatry, and is an adjunct assistant professor of psychiatryat the University of Minnesota Medical School.

Pediatric bipolar disorder from page 21

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Early diagnosis andtreatment arelikely to resultin improvedoutcomes.



Gastric distress is not a souvenir that anyonewants to take away from a family picnic or agraduation open house. Queasiness, bloating,

gas, vomiting, and diarrhea are no fun, not to men-tion the more serious possible outcomes of permanentorgan damage and death.

And while severe or life-threatening complicationsof food poisoning are more likely to occur in the veryyoung and the very old, pregnant women, and theimmunocompromised, anyone can contract a food-borne illness. The risk of many types of food poison-ing rises during warm weather.

Although it’s impossible to determine how manycases of home-related foodborne illness occur eachyear—such incidents are largely unreported and theMinnesota Department of Health (MDH) can’t inves-tigate unreported incidents—it’s nonetheless sensibleto learn how to prepare and store food safely at homeand on the go.

How not to get sickBy April K. Bogard, MPH, RS

Foodborne illness

P U B L I C H E A L T H

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Providing care at multiple modern clinics in Minnesota and Wisconsin

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Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

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Food safety at home

Wash your hands To pre-vent bacteria and virusesfrom contaminating food andcausing illness, don’t preparefood for others while you’resick, especially if you arevomiting or have diarrhea.Wait at least 24 hours afteryour symptoms are gonebefore preparing food forothers. Wash your handsthoroughly before handlingingredients and utensils.Washing hands after taking a

bathroom break is always a must, and even more so when you’repreparing and serving food.

Avoid cross-contamination Bacteria and viruses can be spreadthroughout the kitchen and get onto hands, cutting boards, utensils,countertops, and food. To avoid this:

Before you start preparing food, have all utensils, cooking con-tainers, and ingredients on hand so you don’t have to open drawersor cabinets with hands contaminated by raw food.

Keep raw meat securely contained so that it doesn’t drip ontoother food in the refrigerator or onto countertops. Store raw meaton the bottom shelf of your refrigerator so it doesn’t drip onto otherfoods.

Wash produce All fresh produce, except commercially washed,pre-cut and bagged produce, should be washed under running waterbefore cutting, eating, or cooking. Even if you plan to peel the pro-duce, it is important to wash it under running water first. Scrubitems that have a tough rind or peel, such as carrots, melons, andcitrus. Then, place the food in a colander and rinse thoroughlyunder running water. Blot it dry with a paper towel.

Cook properly Food is cooked safely when it reaches a highenough internal temperature to kill the harmful bacteria that causefoodborne illness. Follow the cooking directions for your oven, grill,slow cooker, and other equipment. Color is not a reliable indicatorof doneness, so always measure the final, cooked, internal tempera-ture of meats by using a digital thermometer (readily available atmost stores that sell kitchen utensils).

Chill quickly Once food is cooked, serve it as quickly as is rea-

sonably possible and promptly refrigerate what isn’t served,because cold temperatures slow the growth of bacteria.

Refrigerate/freeze correctly To facilitate the rapidcooling of foods, get in the habit of doing this:

Divide hot leftovers into small portions and place themin clean containers that weren’t used in the cooking process.This speeds the food’s cooling and enhances air circulationinside the fridge, which additionally cools the food and keepsthe temperature of the fridge from rising too much.

Air circulation is also enhanced by not over-filling thefridge or freezer.

Place a thermometer somewhere in the fridge and an -other one in the freezer. The fridge should be between 35 and 40 degrees F; this keeps food from freezing and also

from getting warm enough to spoil quickly. The freezer shouldbe at or below 0 degrees F.

Food safety during a power outage

If the power goes out, keep refrigerator and freezer doors closed. Anunopened refrigerator will keep food cold for about four hours. Leftunopened, a full freezer will maintain its temperature for approxi-mately 48 hours, and for approximately 24 hours if it is half full. Ifthe power is predicted to be out for a prolonged period of time, putdry ice or block ice in the refrigerator and in the freezer. Fiftypounds of dry ice should maintain the temperature of a full freezerof an 18-cubic-foot fridge for two days.

If food in the freezer is partially or completely thawed by the


Foodborne illness to page 34

Foodborne Illness Hotline Report gastroenteric

illness to MDH: (800) FOOD-ILL

Wash your hands• Wet hands with warm, running water.

• Add soap.

• Rub hands vigorously for 20 seconds. Be sure to wash:

Backs of hands WristsBetween fingers Tips of fingersThumbs Under fingernails

(Use a nailbrush if possible.)

• Rinse, with fingers pointing down.• Dry vigorously with paper or clean cloth towel.• Turn off faucet with towel and open door with towel.


Many of us don’t think ofourselves as caregivers,but when we help

someone with daily needs byshopping, running errands,doing laundry, providing aride to the doctor or drug-store, talking with doctorson behalf of a patient, andhelping that patient under-stand what needs to be done,we are performing caregiver tasks.

Most of us will find ourselves in this role at somepoint, whether as a neighbor, relative, or friend. InMinnesota, one in six people age 18 and older provide

regular care or assistance for afriend or family member who has ahealth problem. The Metropolitan

Caregiver Service Collabor-ative reports the esti mated

annual value of care pro-vided by informal care-givers is $8.9 billion.

Stressors

However, we cannot success -fully care for others unless we are fullyfunctioning. That’s why pilots tell us, in

case of emergency, “Put on your own oxy-gen mask before helping your loved one with

his or hers.” We all understand the importance ofthis message when it relates to a split-second

crisis. Yet, when we look at long-term caregiv-ing, this critical need for self-preservation

can be forgotten.Helping out with occasional tasks feels manage-

able, but when we find ourselves spending anincreased amount of time providing care on an ongoing basis, wecan start to feel overwhelmed. This feeling is understandable whenyou consider that most caregivers in the U.S. also handle job-relatedresponsibilities. The majority of U.S. caregivers are 35–64 years ofage. Of those aged 50–64, an estimated 60 percent work full or parttime. So it is only natural that stress and fatigue impact caregivers.

But it’s important to reduce stress before you reach the breakingpoint. The Family Caregiver Alliance reported in 2007 that care-givers are at increased risk for depression and alcohol abuse, aremore susceptible to chronic conditions, tend to postpone their ownself-care such as routine medical care and needed surgeries, andtherefore have higher mortality rates compared with people whodon’t provide care. How can you recognize the symptoms of stressthat often sneak up on caregivers? Here are 10 common signs.

Symptoms

• Feelings of sadness, loneliness, or depression

• Excessive worrying or anxiety about what tomorrow will bring

• Feelings of frustration and anger at the situation, the care recipi-ent, or both

• Sleep problems/fatigue

• Difficulty concentrating and making decisions

• Weight loss or gain/poor eating habits

• Decreased focus on personal care

• Decreased participation in meaningful activities/social withdrawal

• Decreased physical activity

• Decreased attention to your own medical concerns

T A K E C A R E

Caregiver stressBe kind to yourself By Chris Rosenthal, MSW, LISW

Stress reduction strategies

Although recognizing caregiver stress is important, taking the timeand energy to address it is paramount, both for the health of thecaregiver and for the care recipient. Here are ways to reduce it.• Honor yourself. Most caregivers have had to

make the choice of sacrificing some part oftheir dreams, even if only for the short term,for the benefit of another person. Caregiversoften speak with guilt about feeling resentfulof the time they are devoting to another butyou don’t need to feel guilty because it’s only nat-ural to experience resentment. Your loved one needs you and youare there for your loved one. Give yourself a pat on the back!

• Educate yourself. When I was a first-time mother, I never couldhave managed without the support and knowledge of the commu-nity that surrounded me. I picked up the phone almost daily tocall my mother, my sister, my friends, and the doctor to ask ques-tions. Somehow, caregivers often feel that they should instinctivelyknow what to do in every situation they encounter.

If the person you care for has a specific illness or disability,learn all you can about it. You will feel more in control of the situa-tion when you know more, and you also will be better equipped toadvocate for your care recipient’s health care needs and other needs.

• Learn about resources for caregivers and seek help. Asking forhelp is a sign of strength, not weakness. Contact these types ofsupport networks in your community:

✓ Caregiver coaching and training

✓ Support groups

✓ Respite care

✓ In-home care

✓ Disease-specific associations such asthe Alzheimer’s Association and theMultiple Sclerosis Society

✓ Friends/family/spiritual community

• Take care of yourself. This is the hardest thing of all to do. Oftencaregivers ask, “How can I take time for myself? I have no extratime.” If you think you are being selfish by putting your needsfirst, then you need to know this sobering fact: Thirty percent ofcaregivers die before the person they are caring for dies. If you arenot caring for yourself, you jeopardize your health and, ultimately,your ability to care for your loved one.

To take care of yourself:

✓ Make a list of the things for which you could use help. Givethis list to family members/friends and let them choose thingsthey would like to do.


WHO’S A BIGGER BASEBALLFAN, YOU OR ME?You’ll find that people with Down syndromehave a passion for knowledge and learningthat can rival anyone you’ve met before.To learn more about the rewards of knowing orraising someone with Down syndrome, contactyour local Down syndrome organization.Or visit www.dsamn.org today.

©2007 NationalDown SyndromeCongress

It is the mission of the Down Syndrome Association ofMinnesota to provide information, resources and support toindividuals with Down syndrome, their families and theircommunities. We offer a wide range of services, programs andmaterials at no charge. If you are interested in receiving oneof our information packets for new or expectant parents,please email [email protected] or

For more information please call:

(651) 603-0720 • (800) 511-3696

Caregiver stress to page 32

For more information, including culturally appropriateinformation for Hmong and Spanish-speaking caregivers,visit:

• Metropolitan Caregiver Service Collaborativewww.caregivercollaborative.org

• Family Caregiver Alliance, www.caregiver.org

• National Family Caregivers Associationwww.nfcacares.org

• Caregiver Minnesota, www.caregivermn.org


I N S U R A N C E

One way to payhealth care costs

By Paul Hanson

John has a terminal illness. Most of his med-ical bills have been covered by health insur-ance but his available cash is dwindling. He’sready for hospice care but because his med-ical insurance doesn’t cover it, he needs toraise cash.

One way to do this is through a viatical settlement. A viaticalsettlement typically occurs when a terminally or chronically ill per-son who owns a life insurance policy sells that policy, usually for acertain percentage of the policy’s face value. For example, if John’spolicy pays his beneficiary $100,000 upon his death, John mightfind a viatical settlement broker who would buy the policy for 70percent of its face value. John would therefore get $70,000. Howmuch would John’s spouse, the original beneficiary of John’s poli-cy, receive when John dies?

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Nothing. That’s because whoever buys a life insurance pol -icy through a viatical settlement becomes the beneficiary. In thiscase, the insurance company whose broker bought John’s policywill receive $100,000 when John dies.

Clearly, viatical settlements present potential pitfalls as wellas benefits.

Before entering into a viatical settlement

John should consider:1. Why was the policy originally purchased? Was it to ensure

financial survival of his spouse and their children?2. What are the current financial needs of John and his benefici-

aries? If the children are now self-supporting, they no longerneed financial support that the policy would have provided.

3. If the original reason for the policy no longer exists, are thereother reasons why the policy should be kept? Has John’sspouse developed a medical condition that makes employmentimpossible?

4. Have the future financial needs of John or his beneficiarieschanged?

Presumably, John’s policy met some important financial objec-tive(s) when he bought it. Anyone considering a viatical settlementshould revisit the original reasons for having the policy.

Tax consequences

You may viaticate—i.e., sell—your life insurance policy in Minnesotawithout being either terminally or chronically ill, but you may betaxed on the amount you sell it for, so consult a tax professional.

Two important terms to understand are “terminally ill” and“chronically ill.”

“Terminally ill” means having an illness or sickness that reason-ably can be expected to result in death within 24 months.

“Chronically ill” means: (1) being unable to perform at least twoactivities of daily living such as eating, toileting, bathing, and dress-ing; (2) requiring substantial supervision to protect the individualfrom threats to health and safety due to severe cognitive impairment;or (3) having a level of disability similar to that described in (1).

Non-viatical options

John and his spouse should consider all options available for derivingcash from John’s life insurance and should consult an attorney, taxadvisor, or financial planner when evaluating them:

1. Surrender the life insurance policy to the insurance company for itscash surrender value (CSV), which is less than the face amount ofthe policy.

2. Determine if accelerated death benefits are available from the policy.

3. Take policy loans against the life insurance, i.e., borrow moneyfrom the insurance policy. When John dies, the amount he bor-rowed will be subtracted from the amount the policy pays the beneficiary.

4. Obtain other financing, such as bank loans.

Evaluating options

If John decides to viaticate his life insurance policy, he needs to findout whether:

1. The life insurance brokers or companies giving him quotes (of whatthey’ll pay him for his policy) are properly licensed. To find out,call the Department of Commerce phone number (see sidebar).

2. Viaticating his policy affects his ability to use public assistancesuch as Medicaid.

John should be aware that funds from the settlement may be pursued by creditors if his medical costs lead to credit problems.

If John wants to buy more life insurance

John’s circumstances no longer include dependent children withfuture needs such as college. And with a terminal illness it is unlikelythat he’ll need additional life insurance. However, if he does have


Viatical settlements to page 33

RegulationThe primary regulator of Minnesota’s viatical insurance industry is the Minnesota Department of Commerce. If you feel that youwere taken advantage of in a viatical insurance settlement or that the law was not upheld, file a complaint. 1. Fill out the complaint form at mn.gov/commerce/topics/

consumer-information/Licensed-Industry.jsp2. Mail the form to:

Minnesota Department of Commerce85 7th Place East, Suite 500St. Paul, MN 55101

Or file a complaint by emailing [email protected] For more information, call the Consumer Protection Division of the Department of Commerce at (651) 296-2488 or (800) 657-3602. The Department may investigate and take actions where violations of Minnesota law have occurred.

✓ Promise yourself to take a break from care-giving each week. If an afternoon away seemstoo difficult, start with one hour each weekand pick something meaningful to do duringthat hour. Maybe it’s going for a walk or

going to the local coffeeshop.

✓ Take advantage ofcommunity services to pro-vide a break for you. The loved one

we care for needs more people in hisor her life than just us. As caregivers,

we may start to feel like “No one can do thislike I can.” However, this go-it-alone attitudemay inadvertently worsen the crisis that canoccur if a caregiver is suddenly unable to fulfill

caregiving duties. At such times it is very helpful fora care recipient to have an established relationship

with another trusted caregiver who understandsthe recipient’s needs.

✓ Remember to laugh. This may sound trite, but it is truly help-ful. When you’re a caregiver, so much of life can feel serious.Laughter increases the body’s levels of endorphins, which arechemicals the body manufactures that are natural mood ele-vators. Laughter also helps us take ourselves and the situationless seriously, even if only for the moment.

Rewards

In her book “The Gifts of Caregiving,” author ConnieGoldman says, “Caregiving is probably the most rewarding

thing I’ve done and also the most difficult.” With all thetalk of stress and fatigue, it is important to consider whypeople accept the role of caregiver. One participant in acaregivers’ support group I facilitate explained it this way,

in talking about taking care of his spouse for more than adecade:“The only reward I know for caregiving is the

love you have for the other person, knowing theonly reward will be the look in her eyes whenshe is grateful for something I’ve done ...”

Although caregiving sometimes forces us tosee our loved ones as their least pleasant and mostvulnerable selves, it also allows us to be present for some of themost humorous, tender, and certainly insightful moments in the livesof those we love.

Chris Rosenthal, MSW, LISW, is the director of the Senior ServiceDepartment at Jewish Family Service of St. Paul.

Caregiver stress from page 29


It’s important to reduce stress before you reach the breaking point.

Health Care ConsumerAssociation

Minnesota

Each month, members of the Minnesota HealthCare Consumer Association are invited to participate in a survey that measures opinionsaround topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the April survey.

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Strongly

agree

Does not

apply

Agree Disagree Strongly

disagree

0

10

20

30

40

50

0%

14.71%

8.82%

29.41%

47.06%

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Strongly

agree

Does not

apply


disagree

0

5

10

15

20

25

30

35

40

0%

23.53%

38.24%

26.47%

11.76%

2. My physician recommended a diagnostic procedure,but I have personal concerns that are causing me topostpone action on the recommendation.

1. I have wanted a diagnostic procedure, but my physician played a role in my decision to postponeseeking this care.

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Strongly

agree

Does not

apply


disagree

0

10

20

30

40

50

23.53%

44.12%

2.94%

23.53%

5.88%

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Strongly

agree

Does not

apply


disagree

0

10

20

30

40

50

60

8.82%

14.71%

52.94%

8.82%

14.71%

5. My doctor and I both thought a diagnostic procedurewas necessary, but cost issues caused me to postpone seeking this care.

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Strongly

agree

Does not

apply


disagree

0

5

10

15

20

25

30

11.76%

23.53%

26.47%

23.53%

14.71%

3. An insurance company or health system has made itdifficult to obtain a proposed diagnostic procedure.

April survey results ...

4. I would consider getting a second opinion on the necessity of a diagnostic procedure recommended by my physician.

future life insurance needs, he should realize that a per-son may have so much coverage from life insurancethat it’s not possible to obtain additional life insurance.

That’s because life insurers consider the totalamount of life insurance a person has when underwrit-ing a new policy and may decline to issue one becauseof the amount of life insurance already in effect. Thereason is related to “moral hazard risk.” This meansthat if the amount of coverage on someone is high, itmay change that person’s risk of dying because thatperson is now worth more dead than alive, thus creat-ing a moral hazard.

The viatical settlement process

John is known as the viator—the person selling the life insurance pol-icy—in a viatical settlement. During the selling process John mostlikely will work with a viatical settlement broker. Before decidingwhich broker will buy his policy, it’s a good idea for John to obtainquotes from several licensed viatical settlement brokers. John shouldask these brokers for a better price for his life insurance policy thanthe policy’s CSV. The price John obtains through a viatical settlementwill depend upon many factors, including:

1. His policy’s expected death benefit

2. John’s diagnosis

3. John’s prognosis and its possible variability

4. The present value of any premium payments over John’s expectedremaining life span, i.e., the amount of money John owes for pre-

miums during the time he remains alive

5. The insurer that issued the policy

The viatical settlement process includes independ-ent medical examinations and reviews of medicalrecords to confirm John’s diagnosis and prognosis.Anyone considering a viatical settlement needs to real-ize that personal medical information will beexchanged between multiple parties.

The more John knows about his own financialaffairs and the brokers and businesses he requestsquotes from, the more he will be in the driver’s seat.That will help him get the best price for his policy.

Licensing of viatical settlement brokers is requiredin Minnesota, and determining the licensing status and history of each broker John deals with is impor-

tant. Licensees must submit information about themselves and allowthe state’s Department of Commerce to check their backgrounds.

John should contact the state insurance departments in otherstates where a broker does business, to see if complaints have beenfiled against the broker in those states. Check a broker’s reputationusing multiple sources; information on the Internet is not necessarilytrue. And don’t rush through decisions or the viatical settlementprocess: Selling a life insurance policy is a major decision that willhave an impact on the viator and his or her significant others.

Paul Hanson is chief examiner at the Minnesota Department of Commerce.The opinions expressed in this article are the author’s and donot necessarily reflect those of the Department of Commerce.

Viatical settlements from page 31


Viatical settlements

present potential pitfalls as well

as benefits.

We want to hear from you!

Join now.

SM

Welcome to your opportunity to be heardin debates and discussions that shape thefuture of health care policy. There is nocost to join and all you need to becomea member is access to the Internet. Yourprivacy is completely assured; we won’teven ask your name.

Members receive a free monthly electronicnewsletter and the opportunity toparticipate in consumer opinion surveys.

www.mnhcca.org

Health Care ConsumerAssociation

Minnesota

time power comes back on, don’t taste it to determineits safety! You will have to evaluate each item sepa-rately. Discard any items in either the freezer or therefrigerator that have come into contact with rawmeat juices.

If the freezer thermometer reads 40 degrees F orbelow when the power comes back on, food in thefreezer can safely be left in the freezer to refreeze. If a thermometer has not been kept in the freezer,check each package of food to determine its safety butdon’t rely on appearance or odor. If the food still con-tains ice crystals or is 40 degrees F or below, it is safeto refreeze.

Refrigerated food should be safe as long as poweris out no more than four hours and the fridge door iskept closed. Discard any perishable food (such asmeat, poultry, fish, eggs, milk, cheese, and leftovers)that has been above 40 degrees F for two hours.

And if you’re not sure: When in doubt, throw itout.

Food safety on the go

Prevent cross-contamination When you’re packing the cooler,wrap raw meat securely to avoid its juices coming in contact withready-to-eat foods.

Cook properly Don’t be deceived by the browning of the meat.Color is not a reliable indicator of doneness because many factors

affect the final color of cooked meat, including fatcontent and seasoning. Use a meat thermometer to besure that the meat’s internal temperature has reachedthat recommended by the U.S. Department ofAgriculture (USDA):

• Ground beef = 160 degrees F. Consider using groundbeef treated with irradiation for an extra measure of safety.

• Poultry (including ground chicken and groundturkey) = 165 degrees F.

• Pork = 145 degrees F.

• Whole-muscle meat (chops, steaks, and roasts) = 145 degrees F.

Serve safely Keep cold foods cold and hot foodshot. When serving foods, don’t leave them at roomtemperature for more than two hours. After two hoursat room temperature, discard uneaten food that typi -cally requires refrigeration, such as potato salad, eggsalad, salad dressing, cream pies, cheese, and meat.

Stay healthy

The number of people who get sick from food poisoning goes upduring the summer. Be sure you and your family aren’t among them.

April K. Bogard, MPH, RS, is a supervisor in the food, pools, and lodgingservices area of the MDH.

Foodborne illness from page 27


When servingfoods, don’tleave them

at room temperature

for more thantwo hours.

Elizabeth Klodas, M.D.,F.A.S.C.C is a preventive

cardiologist. She isthe founding Editor inChief of CardioSmartfor the American

College of Cardiologywww.cardiosmart.org,a published author

and medical editor forwebMD. She is a member

of several nationalcommittees on improving

cardiac health and afrequent lecturer on

the topic.

Preventive Cardiology Consultants isfounded on the fundamental belief thatmuch of heart disease can be avoidedin the vast majority of patients, andsignificantly delayed in the rest, by prudentmodification of risk factors and attainablelifestyle measures.

We are dedicated to creating a true part-nership between doctor and patient workingtogether to maximize heart health. Wespend time getting to know each patientindividually, learning about their lives andlifestyles before customizing treatmentprograms to maximize their health.

Whether you have experienced any typeof cardiac event, are at risk for one, or

are interested in learning how to preventone, we can design a set of just-for-yousolutions.

Among the services we provide

• One-on-one consultations withcardiologists

• In-depth evaluation of nutrition andlifestyle factors

• Advanced and routine blood analysis

• Cardiac imaging including (as required)stress testing, stress echocardiography,stress nuclear imaging, coronary calciumscreening, CT coronary angiography

• Vascular screening

• Dietary counseling/Exercise prescriptions

Now accepting new patients

A unique perspective on cardiac care

To schedule an appointment or to learn more about becominga patient, please contact:

Preventive Cardiology Consultants6545 France Avenue, Suite 125, Edina, MN 55435

phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

Important Patient Information

This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you.

WARNING

During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body.

What is Victoza® used for?

• Victoza®isaglucagon-like-peptide-1(GLP-1)receptoragonistusedtoimprovebloodsugar(glucose)controlinadultswithtype2diabetesmellitus,whenusedwithadietandexerciseprogram.

• Victoza®shouldnotbeusedasthefirstchoiceofmedicinefortreatingdiabetes.

• Victoza®hasnotbeenstudiedinenoughpeoplewithahistoryofpancreatitis(inflammationofthepancreas).Therefore,itshouldbeusedwithcareinthesepatients.

• Victoza®isnotforuseinpeoplewithtype1diabetesmellitusorpeoplewithdiabeticketoacidosis.

• ItisnotknownifVictoza®issafeandeffectivewhenusedwithinsulin.

Who should not use Victoza®?

• Victoza®shouldnotbeusedinpeoplewithapersonalorfamilyhistoryofMTCorinpatientswithMEN2.

What is the most important information I should know about Victoza®?

• Inanimalstudies,Victoza®causedthyroidtumors.Theeffectsinhumansareunknown.PeoplewhouseVictoza®shouldbecounseledontheriskofMTCandsymptomsofthyroidcancer.

• Inclinicaltrials,thereweremorecasesofpancreatitisinpeopletreatedwithVictoza®comparedtopeopletreatedwithotherdiabetesdrugs.Ifpancreatitisissuspected,Victoza®andotherpotentiallysuspectdrugsshouldbediscontinued.Victoza®shouldnotberestartedifpancreatitisisconfirmed.Victoza®shouldbeusedwithcautioninpeoplewithahistoryofpancreatitis.

• Seriouslowbloodsugar(hypoglycemia)mayoccurwhenVictoza®isusedwithotherdiabetesmedicationscalledsulfonylureas.Thisriskcanbereducedbyloweringthedoseofthesulfonylurea.

• Victoza®maycausenausea,vomiting,ordiarrhealeadingtothelossoffluids(dehydration).Dehydrationmaycausekidneyfailure.Thiscanhappeninpeoplewhomayhaveneverhadkidneyproblemsbefore.Drinkingplentyoffluidsmayreduceyourchanceofdehydration.

• Likeallotherdiabetesmedications,Victoza®hasnotbeenshowntodecreasetheriskoflargebloodvesseldisease(i.e.heartattacksandstrokes).

What are the side effects of Victoza®?

• Tellyourhealthcareproviderifyougetalumporswellinginyourneck,hoarseness,troubleswallowing,orshortnessofbreathwhiletakingVictoza®.Thesemaybesymptomsofthyroidcancer.

• Themostcommonsideeffects,reportedinatleast5%ofpeopletreatedwithVictoza®andoccurringmorecommonlythanpeopletreatedwithaplacebo(anon-activeinjectionusedtostudydrugsinclinicaltrials)areheadache,nausea,anddiarrhea.

• Immunesystemrelatedreactions,includinghives,weremorecommoninpeopletreatedwithVictoza®(0.8%)comparedtopeopletreatedwithotherdiabetesdrugs(0.4%)inclinicaltrials.

• Thislistingofsideeffectsisnotcomplete.YourhealthcareprofessionalcandiscusswithyouamorecompletelistofsideeffectsthatmayoccurwhenusingVictoza®.

What should I know about taking Victoza® with other medications?

• Victoza®slowsemptyingofyourstomach.Thismayimpacthowyourbodyabsorbsotherdrugsthataretakenbymouthatthesametime.

Can Victoza® be used in children?

• Victoza®hasnotbeenstudiedinpeoplebelow18yearsofage.

Can Victoza® be used in people with kidney or liver problems?

• Victoza®shouldbeusedwithcautioninthesetypesofpeople.

Still have questions?

Thisisonlyasummaryofimportantinformation.Askyourdoctorformorecompleteproductinformation,or

• call1-877-4VICTOZA(1-877-484-2869)

• visitvictoza.com

Victoza® is a registered trademark of Novo Nordisk A/S.

DateofIssue:May2011Version3

©2011NovoNordisk140517-R3June2011

Victoza® helped me take my blood sugar down…

Model is used for illustrative purposes only.

and changed how I manage my type 2 diabetes.Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells.

While not a weight-loss product, Victoza® may help you lose some weight.

And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

If you’re ready for a change, talk to your doctor about Victoza® today.

FOR TYPE 2 DIABETES

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily

Indications and Usage:Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children.

Important Safety Information:In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer.Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis.Before using Victoza®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration.The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies.

Please see Brief Summary of Important Patient Information on next page.

If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW.You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088.Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

Documents

Minnesota Health care News May 2013